Metastatic Carcinoma of the Colon Similar

to Crohn’s Disease:A Case Report

Kohji Tanakaya , Hitoshi Takeuchi , Yoshimasa Yasui , Akira Takeda ,

Yuzo Umeda , and Ichiro Murakami

Department of Surgery and Department of Pathology, Iwakuni National Hospital, Iwakuni 740-8510, Japan

A 68-year-old Japanese man with a history of linitis plastica carcinoma of the stomach and

subsequent gastrectomy 8 years previously presented with lower abdominal pain. Radiological and

endoscopic examinations showed multiple submucosal nodular lesions similar to Crohn’s disease in the

ileocecal area. A firm diagnosis could not be made after initial multiple biopsies. Finally, a

submucosal biopsy revealed adenocarcinoma. The ileocecal lesion was diagnosed as a recurrence

because of the histological findings, which included mucosal preservation, a similarity with the

histologic type of stomach carcinoma, and atypical immunoreactivity for primary colon carcinoma;the lesion was negative for both cytokeratin 7 and cytokeratin 20. In cases where metastatic

carcinoma of the colon is suspected, we recommend early consideration of a submucosal biopsy.

Key words:metastatic carcinoma, colon, Crohn’s disease

M etastatic carcinoma of the colon is rare. It has

been reported to occur in 0.1-1 of colon

malignancies［1］. The diagnosis is defined by clinical and

histologic findings, and is often difficult to make because

the metastatic lesion usually spreads into the submucosal

space preserved with normal mucosa.We report here a case of metastatic ileocecal car-

cinoma. Considering the clinical course and histologic

examination, this case was quite difficult to diagnose.

Case Report

A 68-year-old Japanese man presented with lower

abdominal pain in January 1995.The patient had undergone a total gastrectomy for

linitis plastica carcinoma of the stomach 8 years previous-

ly. Histological evaluations of the gastric carcinoma had

revealed signet ring cell carcinoma with areas of poorly

differentiated adenocarcinoma, and the depth of invasion

was subserosa. The case was classified as a pT2, pN2,sH0, sP0, sM0, f Stage IIIA gastric carcinoma, accord-ing to the Japanese Classification of Gastric Carcinoma［2］. Two of 5 harvested lymph nodes (LN)along the

lesser curvature(LN No. 3)and 1 of 6 LN along the left

gastric artery(LN No. 7)were positive for metastasis.Immunohistochemical examination of the gastric tumor

revealed partially positive staining for cytokeratin 7(DAKO, Denmark)but not for cytokeratin 20(DAKO).The carcinoembryonic antigen(CEA)was elevated to

9.1 ng/ml. A barium enema showed a serrated contour

and stricture of the ileocecal region(Fig. 1). A colono-scopy showed multiple submucosal nodular lesions of the

cecum(Fig. 2). The lesions were similar in appearance to

the cobblestone appearance of Crohn’s disease but without

ulceration. We weren’t able to obtain a firm diagnosis by

routine multiple biopsies. Finally, 50 days after admis-

Received August 4,2003;accepted February 26,2004.Corresponding author.Phone:＋81-827-31-7121;Fax:＋81-827-31-7059

E-mail:tanakaya＠iwakuni-nh.go.jp(K.Tanakaya)

http://www.lib.okayama-u.ac.jp/www/acta/

Acta Med. Okayama, 2004

Vol. 58, No. 4, pp. 217-220

Case Report

Copyrightｃ2004 by Okayama University Medical School.

sion, a diagnosis of adenocarcinoma was made by a

submucosal biopsy using a strip biopsy technique［3］.The patient underwent an ileocecal resection.Gross exploration of the abdomen showed that the

recurrence had occurred solely in the ileocecal area.Gross findings of the resected specimen demonstrated

intestinal wall thickening and multiple submucosal nodular

lesions covered with normal mucosa(Fig. 3).Histological examination of the resected specimen

revealed signet ring cell carcinoma with areas of poorly

differentiated adenocarcinoma expanding from the sub-mucosa to the subserosa. Mucosal preservation was

clearly demonstrated by positive staining for CAM5.2(DAKO)(Fig. 4). Two of 11 harvested lymph nodes(LN)along the paracolic vessels were positive for metas-tasis. Neither cytokeratin 7 nor cytokeratin 20 revealed

immunoreactivity in the ileocecal lesion.Although 8 years had passed since the gastrectomy,

the ileocecal lesion was diagnosed as a metastasis from

gastric carcinoma because of histologic findings such as

mucosal preservation and a similarity to stomach car-cinoma. The patient died from peritoneal dissemination of

the carcinoma 16 months after the second surgery.

Discussion

Metastatic carcinoma of the colon usually originates

from carcinoma of the stomach, breast, skin, kidney,prostate, or ovary［4, 5］.Findings of the history-taking and examination are

very important for making a diagnosis of metastatic

carcinoma. A recurrence of stomach carcinoma usually

occurs within 5 years of surgery, often in multiple organs.In the present case, the recurrence occurred after a long

interval from the initial stomach carcinoma, and the

ileocecal area was the only lesion in which recurrence was

Tanakaya et al. Acta Med. Okayama Vol. 58, No. 4 218

Fig.1 A barium enema showed a serrated contour and stricture of

the ileocecal region(arrow heads).

Fig. 3 Gross findings of the resected specimen demonstrated

intestinal wall thickening and multiple submucosal nodular lesions

covered with normal mucosa(arrow heads).

Fig.2 A colonoscopy showed multiple submucosal nodular lesions

of the cecum.

suspected. Recurrence was suspected because of the

CEA elevation, but the CEA is often elevated by other

mechanisms.In cases with metastatic carcinoma of the colon, a

barium enema usually reveals segmental colonic strictures.Endoscopic examination normally shows granular and

friable lesions with a loss of the normal vascular pattern,occasionally with submucosal nodularity or superficial

erosions［6］, and rarely polyposis［4］.Metastatic carcinoma of the colon can be misdiagnosed

as primary linitis plastica carcinoma, Crohn’s disease,ischemic colitis, tuberculosis, or diverticulitis［6］.Several authors have reported cases with metastatic

carcinoma of the colon similar to Crohn’s disease［6-9］.In cases with Crohn’s disease, there is often colonic

involvement. A barium enema reveals a stenotic bowel

segment and nodular irregularity, the so-called “string

sign”and“cobblestone appearance,”respectively.In cases showing linitis plastica carcinoma or signet

ring cell carcinoma of the colon, the differentiation

between primary and metastatic carcinoma is often made

by the exclusion of other malignancies. Primary signet

ring cell carcinoma is a rare form of colorectal malignancy

usually affecting young patients, and the differentiation is

not always clear at microscopy. Primary carcinoma

infiltrates from the mucosa to the serosa, with metastatic

lesions beginning as submucosal or serosal implants.Recently, immunohistochemical examination for cytoker-atin 7 and cytokeratin 20 has been reported to be useful

for differentiation between signet ring cell carcinoma of the

Metastatic Carcinoma of the Colon August 2004

Fig.4 Histological examination of the stomach and ileocecal lesion. A, The stomach lesion showed signet ring cell carcinoma. HE stain,high power field. Bar indicates 20μm. B, The ileocecal lesion showed mucosal preservation, as clearly demonstrated by positive staining

for CAM5.2. ABC method, low power field. Bar indicates 500μm. C, The ileocecal lesion showed the signet ring cell carcinoma with areas

of poorly differentiated adenocarcinoma expanding from the submucosa to the subserosa. HE stain, middle power field. Bar indicates 50μm.D, The ileocecal lesion showed signet ring cell carcinoma. HE stain, high power field. Bar indicates 20μm.

219

stomach and colon［10］. A colon primary is supported if

the neoplastic cells have a cytokeratin 7(－)/cytokeratin

20(＋)staining pattern, and a gastric primary is support-ed if the cells have a cytokeratin 7(＋)/cytokeratin 20(－)staining pattern.In the present case, the gastric lesion revealed a

partially positive staining pattern for cytokeratin 7 and a

negative staining pattern for cytokeratin 20, while the

ileocecal lesion revealed negative patterns for both cyto-keratin 7 and cytokeratin 20. Although metastatic lesions

sometimes reveal histologic features different from those

of the primary lesion, the ileocecal lesion did not show a

typical staining pattern for colon signet ring cell car-cinoma. In the present case, the ileocecal lesion was

diagnosed as a recurrence because of the histologic

findings, which included mucosal preservation, a similar-ity to the histologic type of stomach carcinoma, and

atypical cytokeratin 7 and cytokeratin 20 staining patterns

for primary colon carcinoma.The usual endoscopic biopsy often fails to define the

diagnosis. In the present case, we initially suspected

Crohn’s disease or malignant lymphoma, and we required

50 days to make a correct diagnosis using a strip biopsy

resection technique［3］. The biopsy specimen obtained

by this technique includes both submucosal and mucosal

tissues. Therefore, when metastatic carcinoma of the

colon is suspected, we recommend early consideration of

a submucosal biopsy.

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